Suicide following release from custody - Hertfordshire Constabulary, June 2016

On 6 June 2016, a Hertfordshire Constabulary officer arrested a man for alleged theft, and took him to Stevenage police station. During his time in custody, the man was assessed by a contracted healthcare professional (HCP) as fit to be interviewed. The HCP recorded his risk of suicide as ‘standard’. On 7 June, the man was charged with theft and released on bail. Within the man’s custody record, the pre-release risk assessment section was left blank.

On 8 June, the man took his own life. Upon hearing of his death, a police officer made a statement in which they detailed overhearing the man’s sharing suicidal thoughts with the HCP during his medical assessment.

Hertfordshire Constabulary referred this to us on 9 June as a death or serious injury referral.

During the investigation, investigators interviewed and obtained statements from police officers, police civilian staff and non-police witnesses. The investigation also obtained and examined custody CCTV, the man’s custody record, his medical assessment record and relevant national and local police policies and procedures as well as the contractor’s.

Investigators served gross misconduct notices on, and subsequently interviewed, one police officer who was responsible for completing the pre-release risk assessment and the contracted HCP who was responsible for completing the medical assessment in custody.

The Investigator was of the opinion that:

• There was insufficient evidence upon which a reasonable tribunal could conclude that the police officer had a case to answer for gross misconduct.
• The actions of the officer, although not amounting to a case to answer for gross misconduct, fell below the standard expected and their performance was unsatisfactory.
• The contracted HCP had a case to answer for gross misconduct.

The HCP resigned before any misconduct proceedings could be brought against them. We referred the HCP to the Nursing and Midwifery Council and, following a fitness to practice investigation and subsequent hearing, they received a striking off order.

The investigation also identified three potential areas for improvement for Hertfordshire Constabulary:

• compliance with requirement for pre-release risk assessments to be completed in custody
• intermittent audio coverage for CCTV in Stevenage Custody
• reliability of the handwritten custody record

Following consultation with the force, we concluded that sufficient measures were being implemented to address the points above, and that we would not issue formal learning recommendations.

We also concluded that the measures put in place by the force in respect of point 1 above, such as further training, sufficiently addressed our concerns about the performance of the police officer, and that no further action was therefore required to address this.